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Menon R, Saxena R, Pathak M, Yadav T. Hepatopulmonary fusion in congenital diaphragmatic hernia: successful management of a lethal variant. BMJ Case Rep 2024; 17:e260486. [PMID: 38926130 DOI: 10.1136/bcr-2024-260486] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/28/2024] Open
Abstract
Congenital diaphragmatic hernia (CDH) is a congenital anomaly involving the herniation of intra-abdominal contents into the thoracic cavity. Hepatopulmonary fusion (HPF), an exceedingly rare subtype mainly associated with right-sided CDH, presents unique diagnostic and therapeutic challenges. This case report describes a male infant with right-sided CDH complicated by HPF. The intricate anatomical anomaly involved the fusion of the right lung to the liver, posing challenges during surgical separation. The patient experienced postoperative complications, including prolonged ventilation, tracheostomy and pulmonary issues, which led to a prolonged hospital stay. Intraoperative challenges stem from the absence of demarcation between lung and liver tissues and abnormal vascular structures. In summary, managing HPF in right-sided CDH necessitates a customised, multidisciplinary approach to optimise patient outcomes, highlighting the need for ongoing research to refine understanding and treatment strategies.
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Affiliation(s)
- Revathy Menon
- Paediatric Surgery, AIIMS Jodhpur, Jodhpur, Rajasthan, India
| | - Rahul Saxena
- Paediatric Surgery, AIIMS Jodhpur, Jodhpur, Rajasthan, India
| | - Manish Pathak
- Paediatric Surgery, AIIMS Jodhpur, Jodhpur, Rajasthan, India
| | - Taruna Yadav
- Diagnostic and Interventional Radiology, All India Institute of Medical Sciences Jodphur, Jodhpur, Rajasthan, India
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Rocha GMD. Congenital Hepatopulmonary Fusion. Eur J Pediatr Surg 2022; 32:477-496. [PMID: 36027900 DOI: 10.1055/s-0042-1749213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Congenital hepatopulmonary fusion (HPF) is a rare anomaly characterized by a fusion between the liver and lung parenchyma. HPF cases have been scarcely reported in the literature. An extensive search of publications was performed in the PubMed and Google Scholar databases without a time limit. In total, 34 clinical case reports were found in the literature, and a study by the Congenital Diaphragmatic Hernia (CDH) Study Group reported data on 10 patients with HPF. Of these 44 infants, 20 were male, 20 were female, and four were reported without gender specification. Nineteen (43.2%) patients required intubation on the first day of life. Six (13.6%) patients had their clinical presentation during the first year of life, and four (9%) clinically presented with HPF between 2.5 and 11 years of age. In these patients, cough, asthma-like symptoms, dyspnea, hemoptysis, right-side chest pain, respiratory infections, and pneumonia were the relevant clinical signs. Right-lung vascular anomalies were present in 18 (40.9%) patients. A complete liver and lung separation was successful in 17 (38.6%) patients. The overall survival was 56.8%. Congenital HPF has no gender predominance. In most cases, it behaves similar to a right CDH in need of resuscitation and intubation after birth. The majority of the cases are discovered during the surgical procedure for CDH. The best surgical approach has not been established and depends on the degree of fusion and vascular anomalies. An advanced imaging assessment is necessary before a surgical approach is attempted. The prognosis is ominous.
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Affiliation(s)
- Gustavo M D Rocha
- Department of Neonatology, Centro Hospitalar Universitário de São João, Porto, Portugal
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Al-Zaiem M, Raml EI, Alsulaimani N, Alzahrani L, alzahrani A, Turki A. Right congenital diaphragmatic hernia associated with hepatic pulmonary fusion. JOURNAL OF PEDIATRIC SURGERY CASE REPORTS 2022. [DOI: 10.1016/j.epsc.2022.102540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
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Abstract
Hepatic pulmonary fusion (HPF) is a very rare congenital disease which is characterized by a fibrous connection between the liver and lung tissues. It is commonly associated with congenital diaphragmatic hernia (CDH), pulmonary sequestration, congenital heart disease and other diseases. Surgical operation has been reported to be the only option for the treatment of this disease. The most sophisticated point lies in how to define the dividing line between liver and lung fusion tissues. And the postoperative mortality is high. At present, the etiology and pathogenesis of HPF are not completely clear. In this study, we reported a case of a 4-month-old male infant presented with cough and shortness of breath and intraoperatively found to have HPF associated with atrial septal defect and scimitar syndrome. Staged surgery was performed to avoid the simultaneous involvement of multiple organs such as heart, lung and liver, and shorten the operation and anesthesia time to a certain extent, improving the success rate of the operation. We only separated the fusion tissues and repaired the diaphragmatic hernia in the first operation, and in the second surgery, we conducted intra-cardiac repair of cardiac malformations. The follow-up results showed that the right lung gradually developed and there were no significant abnormalities in liver. This experience can provide a useful reference for future cases.
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Affiliation(s)
- Yewei Xie
- Department of Pediatric Cardiothoracic Surgery, Shanghai Children's Hospital, Shanghai Jiao Tong University, Shanghai, China
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Right-Sided Congenital Diaphragmatic Hernia Caused by Hepatopulmonary Fusion. Case Rep Pediatr 2020; 2020:8851341. [PMID: 33178472 PMCID: PMC7644339 DOI: 10.1155/2020/8851341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Revised: 09/16/2020] [Accepted: 10/19/2020] [Indexed: 12/01/2022] Open
Abstract
Introduction Hepatopulmonary fusion is a very rare finding associated with right-sided congenital diaphragmatic hernia. With less than 50 reported cases, management and outcomes of hepatopulmonary fusion are poorly understood. This report highlights that clinical presentation is not a reliable indicator of outcomes in this rare disease. Case Presentation. A term neonate admitted for tachypnea and complete opacification of the right hemithorax was diagnosed with right-sided congenital diaphragmatic hernia. Preoperative respiratory support was minimal, and the only symptom exhibited was tachypnea. During surgical repair, fusion of the lung and liver were noted, consistent with a diagnosis of hepatopulmonary fusion. Postoperatively, the patient's pulmonary hypertension worsened and required extracorporeal membrane oxygenation. Conclusions Many patients with hepatopulmonary fusion and only mild symptoms die postoperatively from severe pulmonary hypertension and progressive respiratory failure. Preoperative clinical status is not indicative of postoperative outcomes, and literature suggests that patients who require less support preoperatively have high mortality rates. The availability of ECMO for postoperative complications may be necessary in patients requiring repair of hepatopulmonary fusion.
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Hepatopulmonary fusion: A rare variant of congenital diaphragmatic hernia. J Pediatr Surg 2020; 55:1903-1907. [PMID: 31708208 DOI: 10.1016/j.jpedsurg.2019.09.037] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2019] [Revised: 09/15/2019] [Accepted: 09/16/2019] [Indexed: 11/24/2022]
Abstract
BACKGROUND Hepatopulmonary fusion (HPF), a rare anomaly associated with right congenital diaphragmatic hernia (CDH), is characterized by a fibrovascular fusion between herniated liver and lung parenchyma. We aimed to clarify patient characteristics, management strategies, and outcomes in HPF. METHODS Data on infants with HPF were obtained from the Congenital Diaphragmatic Hernia Registry (CDHR). Patient characteristics, management, and outcomes were compared with the results of a literature review. RESULTS Ten cases of HPF were identified in the CDHR. Five patients survived. The median estimated gestational age was 38 weeks (range 36-40). Median birth weight was 2.7 kg (range 2.0-3.8 kg), but non-survivors had a lower median birth weight (2.3 kg vs. 3.5 kg). All patients had at least 1 congenital anomaly in addition to CDH. Operative approach varied, but most surgeons performed only partial separation of the liver and lung (n = 6). The 2 patients who underwent complete separation both ultimately died, 1 due to significant postoperative complications and 1 due to severe pulmonary hypertension with multiple vascular anomalies. CONCLUSION Partial separation of liver and lung appears to be the wisest surgical approach in HPF, as complete separation has resulted in catastrophic complications due to frequent underlying vascular anomalies. LEVEL OF EVIDENCE IV.
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Kerkeni Y, Farhani R, Sassi N, Hamzaoui M. How to treat hepatic pulmonary fusion: case report with review of literature. Acta Chir Belg 2020; 120:50-52. [PMID: 30203718 DOI: 10.1080/00015458.2018.1496568] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Introduction: Hepatic pulmonary fusion (HPF) occurring with right diaphragmatic hernia is rare. Some sporadic reports exist in the literature. It may range from just fibrovascular communication to complete parenchymal fusion which may be complex to divide.Patients and methods: We report a case of a 1-day old newborn male presented with respiratory distress relevant to a right diaphragmatic hernia.Results: The patient was operated after initial stabilization. During surgery, a 10-cm wide posterolateral defect was found. The herniated liver was only partially reducible because of HPF. This rare condition was treated by the division of the fusion and diaphragm repair using a vicryl patch.Conclusion: Through our case and a review of the literature, we will discuss the different alternatives in the treatment of HPF.
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Affiliation(s)
- Yosra Kerkeni
- Department of Pediatric Surgery "A", Children Hospital "Bechir Hamza" of Tunis, Université de Tunis El Manar Faculté de Médecine de Tunis, Tunis, Tunisia
| | - Rabeb Farhani
- Department of Pediatric Surgery "A", Children Hospital "Bechir Hamza" of Tunis, Université de Tunis El Manar Faculté de Médecine de Tunis, Tunis, Tunisia
| | - Nizar Sassi
- Department of Pediatric Surgery "A", Children Hospital "Bechir Hamza" of Tunis, Université de Tunis El Manar Faculté de Médecine de Tunis, Tunis, Tunisia
| | - Mourad Hamzaoui
- Department of Pediatric Surgery "A", Children Hospital "Bechir Hamza" of Tunis, Université de Tunis El Manar Faculté de Médecine de Tunis, Tunis, Tunisia
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Almaramhy HH. Hepatopulmonary fusion associated with right-sided congenital diaphragmatic hernia: management of this rare anomaly and a review of the literature. J Int Med Res 2018; 46:5278-5284. [PMID: 30352531 PMCID: PMC6300937 DOI: 10.1177/0300060518759892] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Hepatopulmonary fusion is a rare malformation that is often discovered during operative repair of right-sided congenital diaphragmatic defects. Based on a search using medical search engines, we only found 22 cases of hepatopulmonary fusion in the English literature worldwide to date. We describe herein a case of hepatopulmonary fusion with right-sided congenital diaphragmatic hernia in a female neonate who presented with respiratory distress. We discuss management of this case and review the relevant literature.
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Affiliation(s)
- Hamdi H Almaramhy
- Department of Surgery, College of Medicine, Taibah University, Almadinah Almunawwarah, Saudi Arabia
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Abstract
Neonatal surgery is recognized as an independent discipline in general surgery, requiring the expertise of pediatric surgeons to optimize outcomes in infants with surgical conditions. Survival following neonatal surgery has improved dramatically in the past 60 years. Improvements in pediatric surgical outcomes are in part attributable to improved understanding of neonatal physiology, specialized pediatric anesthesia, neonatal critical care including sophisticated cardiopulmonary support, utilization of parenteral nutrition and adjustments in fluid management, refinement of surgical technique, and advances in surgical technology including minimally invasive options. Nevertheless, short and long-term complications following neonatal surgery continue to have profound and sometimes lasting effects on individual patients, families, and society.
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Affiliation(s)
- Mauricio A Escobar
- Pediatric Surgery, Mary Bridge Children׳s Hospital, PO Box 5299, MS: 311-W3-SUR, 311 South, Tacoma, Washington 98415-0299.
| | - Michael G Caty
- Section of Pediatric Surgery, Department of Surgery, Yale-New Haven Children׳s Hospital, New Haven, Connecticut
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Hepatopulmonary fusion in a newborn. An uncommon intraoperatory finding during right congenital diaphragmatic hernia surgery: case description and review of literature. Hernia 2013; 18:417-21. [DOI: 10.1007/s10029-012-1042-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2012] [Accepted: 12/27/2012] [Indexed: 10/27/2022]
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Lin J, Durham MM, Ricketts R, Abramowsky CR, Steelman CK, Shehata BM. Hepatic pulmonary fusion: two cases with diaphragmatic hernia and one case with Pentalogy of Cantrell. Fetal Pediatr Pathol 2012; 31:401-9. [PMID: 22497683 DOI: 10.3109/15513815.2012.659406] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Hepatic pulmonary fusion (HPF) is characterized by a fibrous connection between the liver and lung tissue. We present two cases of hepatic pulmonary fusion diagnosed with right diaphragmatic hernia and a third case with Pentalogy of Cantrell exhibiting complete agenesis of the diaphragm and finger-like projections of liver adhered to the right lung. It has been proposed that this anomaly is secondary to developmental failure of the mesoderm between days 14-18 after conception and is attributed to diaphragmatic maldevelopment. Understanding the molecular-genetic basis of diaphragmatic hernias may shed light on this unusual presentation and explain why other cases show no fusion.
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Affiliation(s)
- Jenny Lin
- Department of Pathology, Children's Healthcare of Atlanta, Atlanta, Georgia 30322, USA
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Breysem L, Vanhaesebrouck S, Gewillig M, Dymarkowski S, Smet MH. Multidetector CT of right-sided congenital diaphragmatic hernia associated with hepatopulmonary fusion in a newborn. Pediatr Radiol 2012; 42:1138-41. [PMID: 22476664 DOI: 10.1007/s00247-012-2379-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2011] [Revised: 12/21/2011] [Accepted: 01/15/2012] [Indexed: 11/25/2022]
Abstract
We present a neonate with a complex congenital cardiopathy and a right-sided diaphragmatic hernia complicated with hepatopulmonary fusion. Radiography, abdominal US and multidetector CT (MDCT) demonstrated right-sided lung hypoplasia and liver herniation. In addition, MDCT angiography showed abnormal pulmonary vascular anatomy. At surgery, a right-sided diaphragmatic hernia with a partially herniated liver and hepatopulmonary fusion was confirmed. There was no aberrant systemic vascular supply towards the lower lobe, as seen in extralobar sequestration. MDCT angiography of the chest and upper abdomen with optimal enhancement and reconstruction of the pulmonary and hepatic vasculature can demonstrate associated anomalies in cases of suspected primary or secondary right lung hypoplasia.
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Affiliation(s)
- Luc Breysem
- Department of Radiology, University Hospitals Leuven, Herestraat 49, 3000 Leuven, Belgium.
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Chandrashekhara SH, Bhalla AS, Gupta AK, Sharma PK, Agarwala S, Srinivas M, Mathur S. Hepatic pulmonary fusion: case report with review of literature. J Pediatr Surg 2011; 46:e23-7. [PMID: 21376183 DOI: 10.1016/j.jpedsurg.2010.11.032] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2010] [Revised: 09/26/2010] [Accepted: 11/04/2010] [Indexed: 10/18/2022]
Abstract
Hepatic pulmonary fusion is a rare congenital anomaly and is associated with abnormal systemic venous drainage and arterial supply. We describe multidetector computed tomography and magnetic resonance angiogram findings of an 11-year-old boy with recurrent cough, fever, and respiratory distress caused by hepatic pulmonary fusion.
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Affiliation(s)
- S H Chandrashekhara
- Department of Radio-diagnosis, All India Institute of Medical Sciences, New Delhi, India
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Multidetector computed tomography evaluation of secondary hepatopulmonary fusion in a neonate. Clin Imaging 2010; 34:234-8. [PMID: 20416490 DOI: 10.1016/j.clinimag.2009.07.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2009] [Accepted: 07/20/2009] [Indexed: 11/21/2022]
Abstract
Hepatopulmonary fusion is a rare condition in which a dense adhesion occurs between the right lung and herniated hepatic parenchyma in patients with right-sided congenital diaphragmatic hernia. Plain radiographic and magnetic resonance imaging (MRI) findings of hepatopulmonary fusion in a neonate have been reported in a retrospective study with a small patient population and a case report. However, to our knowledge, there is no report regarding the secondary hepatopulmonary fusion (after right-sided congenital diaphragmatic hernia repair) evaluated with multidetector computed tomography (MDCT) in a neonate. We report a case of secondary hepatopulmonary fusion in a neonate, in which multiplanar and three-dimensional (3D) images were helpful in delineating the precise anatomy for preoperative evaluation. Understanding the diagnostic limitations of plain radiographs and MRI, the use of MDCT with its multiplanar and 3D imaging may emerge as a useful noninvasive imaging modality in the evaluation of possible hepatopulmonary fusion in pediatric patients with right-sided congenital diaphragmatic hernia.
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Gander JW, Kadenhe-Chiweshe A, Fisher JC, Lampl BS, Berdon WE, Stolar CJ, Zitsman JL. Hepatic pulmonary fusion in an infant with a right-sided congenital diaphragmatic hernia and contralateral mediastinal shift. J Pediatr Surg 2010; 45:265-8. [PMID: 20105618 PMCID: PMC4418537 DOI: 10.1016/j.jpedsurg.2009.10.090] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2009] [Revised: 10/27/2009] [Accepted: 10/28/2009] [Indexed: 11/29/2022]
Abstract
Hepatic pulmonary fusion is extremely rare with only 9 previous cases reported in the literature. In typical cases, the clinician should be alerted to the possibility of hepatic pulmonary fusion if the chest radiograph shows a large opacity on the right side without a contralateral mediastinal shift. The authors present a case of right-sided diaphragmatic hernia and hepatic pulmonary fusion with associated contralateral mediastinal shift discovered beyond the neonatal period. The 9 previous cases were retrospectively reviewed with special attention to mediastinal shift on preoperative chest radiograph, operative procedure, and mortality. Only one previous case demonstrated a contralateral mediastinal shift. The most common procedure performed was partial separation of the hepatic pulmonary fusion and approximation of the diaphragmatic defect. Four of the previous 9 patients died. In our case, reduction of bowel and approximation of the diaphragmatic defect around the fused liver and lung have been successful.
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Affiliation(s)
- Jeffrey W. Gander
- Division of Pediatric Surgery, Department of Surgery, Columbia University College of Physicians and Surgeons, Morgan Stanley Children’s Hospital of New York - Presbyterian, Columbia University Medical Center, New York, NY 10032
| | - Angela Kadenhe-Chiweshe
- Division of Pediatric Surgery, Department of Surgery, Columbia University College of Physicians and Surgeons, Morgan Stanley Children’s Hospital of New York - Presbyterian, Columbia University Medical Center, New York, NY 10032
| | - Jason C. Fisher
- Division of Pediatric Surgery, Department of Surgery, Columbia University College of Physicians and Surgeons, Morgan Stanley Children’s Hospital of New York - Presbyterian, Columbia University Medical Center, New York, NY 10032
| | - Brooke S. Lampl
- Division of Pediatric Radiology, Department of Radiology, Columbia University College of Physicians and Surgeons, Morgan Stanley Children’s Hospital of New York - Presbyterian, Columbia University Medical Center, New York, NY 10032
| | - Walter E. Berdon
- Division of Pediatric Radiology, Department of Radiology, Columbia University College of Physicians and Surgeons, Morgan Stanley Children’s Hospital of New York - Presbyterian, Columbia University Medical Center, New York, NY 10032
| | - Charles J. Stolar
- Division of Pediatric Surgery, Department of Surgery, Columbia University College of Physicians and Surgeons, Morgan Stanley Children’s Hospital of New York - Presbyterian, Columbia University Medical Center, New York, NY 10032
| | - Jeffrey L. Zitsman
- Division of Pediatric Surgery, Department of Surgery, Columbia University College of Physicians and Surgeons, Morgan Stanley Children’s Hospital of New York - Presbyterian, Columbia University Medical Center, New York, NY 10032,Corresponding Author. Please send all correspondence to: Jeffrey L. Zitsman, MD, Division of Pediatric Surgery, Children’s Hospital of New York-Presbyterian, 3959 Broadway, CHN 212, New York, NY 10032, Phone: 212-342-8585; Fax: 212-305-9270,
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Fisher JC, Jefferson RA, Arkovitz MS, Stolar CJH. Redefining outcomes in right congenital diaphragmatic hernia. J Pediatr Surg 2008; 43:373-9. [PMID: 18280293 DOI: 10.1016/j.jpedsurg.2007.10.049] [Citation(s) in RCA: 73] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2007] [Accepted: 10/09/2007] [Indexed: 01/18/2023]
Abstract
PURPOSE Available data comparing the management and outcome of right-sided (R-CDH) vs left-sided congenital diaphragmatic hernia (L-CDH) are inconsistent. Large-volume CDH studies are limited by small numbers of R-CDH or are confounded by compilations from multiple institutions with multiple treatment strategies. Consequently, they are underpowered to draw conclusions. To define the behavior and outcomes of R-CDH better, we report the largest single-institution series of R-CDH and ask if factors traditionally linked to poor prognosis in L-CDH were applicable to R-CDH. METHODS We reviewed a single institution's experience with 267 consecutive evaluable neonates with unilateral CDH repaired from 1990 to 2006, with specific focus on R-CDH. chi(2) tests were performed for disease-related categorical variables. Two-tailed unpaired t tests were used for continuous variables. Factors associated with morbidity and survival were determined by univariate regression. Statistical significance was set at P < .05. RESULTS Forty right-sided (15%) and 227 (85%) left-sided cases of CDH were identified. Prenatal diagnosis was made in 20 right-sided vs 170 left-sided defects (50% vs 75%, P < .01). Survival was 22 of 40 in R-CDH compared with 175 of 227 in L-CDH (55% vs 77%, P < .01). Extracorporeal membrane oxygenation was required in 16 right-sided and 33 left-sided cases (40% vs 15%, P < .001). A diaphragmatic patch was used in 22 of 29 right-sided compared with 82 of 199 left-sided repairs (76% vs 41%, P < .01); rates of abdominal wall prosthesis were also higher in right-sided hernias (38% vs 19%, P < .05). No differences were detected in right-sided vs left-sided recurrences (14% vs 8%, P = .38), mean time from birth to operation (5.3 vs 4.8 days, P = .80), or presence of cardiac anomalies (15% vs 12%, P = .63). Morbidity persisting beyond 6 months of age was present in 16 of 22 R-CDH survivors compared with 76 of 175 L-CDH survivors (73% vs 43%, P > .05). Among R-CDHs, prenatal diagnosis was the only factor to predict survival by univariate regression (P < .01). Use of a prosthesis in the diaphragm (P < .05) for R-CDH repair correlated with morbidity. CONCLUSION Although previous reports suggest that associated anomalies, need for extracorporeal membrane oxygenation, and time to repair can influence L-CDH survival, these data do not support extrapolation to R-CDH survival. Right-sided CDH carries a disproportionately high morbidity and mortality. Prenatal diagnosis was the only factor predictive of R-CDH survival. Morbidity may correlate with use of prosthetic material for R-CDH repair. Right-sided CDH is a unique disease that may require a modified antenatal consultation.
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Affiliation(s)
- Jason C Fisher
- Division of Pediatric Surgery, Columbia University College of Physicians and Surgeons New York, NY 10032, USA.
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Fisher JC, Jefferson RA, Kuenzler KA, Stolar CJH, Arkovitz MS. Challenges to cannulation for extracorporeal support in neonates with right-sided congenital diaphragmatic hernia. J Pediatr Surg 2007; 42:2123-8. [PMID: 18082723 DOI: 10.1016/j.jpedsurg.2007.08.007] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2007] [Revised: 08/01/2007] [Accepted: 08/01/2007] [Indexed: 12/01/2022]
Abstract
Right-sided diaphragmatic defects represent less than 20% of all congenital diaphragmatic hernias (CDH). Recent data suggest that right CDH (R-CDH) may carry a disproportionately high morbidity as well as increased rates of extracorporeal support when compared with left CDH. Treatment of infants with R-CDH may be further complicated by anatomical distortion unique to right-sided defects. We report 2 cases of azygous vein cannulation in neonates with large isolated R-CDH. Both infants had postnatal deteriorations within 48 hours, met our criteria for extracorporeal membrane oxygenation (ECMO), and underwent venoarterial cannulations through the right neck. In each case, the venous cannula passed directly into the azygous vein and failed to provide adequate ECMO support. Echocardiography confirmed both cases of azygous cannulation. In one child, the right atrium was successfully cannulated after 90 minutes of extensive cannula manipulation. This child survived a 5-day ECMO course and is alive at 22-month follow-up. In the second child, despite prolonged efforts at cannula repositioning, cannulation of the right atrium was not achieved. We did not offer central cannulation because of a rapidly deteriorating clinical course, with expiration in several hours. At autopsy, a dilated azygous vein was evident as a result of inferior vena cava compression by a malpositioned liver. The possibility of azygous vein cannulation may be increased in neonates with R-CDH and has not been previously reported. When evaluating infants with R-CDH for ECMO, clinicians must recognize the possibility of azygous cannulation and its potentially lethal consequences, and should anticipate alternative venous cannulation.
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Affiliation(s)
- Jason C Fisher
- Division of Pediatric Surgery, Morgan Stanley Children's Hospital of New York-Presbyterian, Columbia University Medical Center, New York, NY 10032, USA.
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Abstract
BACKGROUND Prenatal diagnosis and outcome of right congenital diaphragmatic hernia (RCDH) are far less well known than the more common left CDH (LCDH). In addition, onset of RCDH beyond the neonatal period with a spectrum of atypical symptoms is not unusual. A retrospective analysis of RCDH treated at a single center over 18 years has been reviewed with regard to outcome after the introduction of a new treatment protocol for CDH. METHODS All charts of patients with CDH between 1987 and 2004 were reviewed. Twenty-nine patients with RCDH were identified. The patients were divided into 2 historical groups: group 1, from 1987 to 1998 (16 patients), and group 2, from 1999 to 2004 (13 patients). From 1999, at the Department of Pediatric Surgery of Padua, the management of a baby born with CDH has been standardized and includes planned delivery at term, high-frequency oscillatory ventilation since birth, inhaled nitric oxide if required, extracorporeal membrane oxygenation as a "last resort," and delayed repair once the infant is hemodynamically stable. Patients with either prenatal diagnosis of RCDH or early onset of symptoms (<6 hours of life) were considered "high risk," and those with late onset (>6 hours) were considered "low risk." RESULTS Of 29 patients, prenatal diagnosis was available in 8 (27.5%) and major associated malformations in 8 patients (27.5%). Eight (50%) of 16 cases from group 1 and 9 (69.2%) of 13 cases from group 2 were high-risk patients. There was a trend in favor of a higher survival among high-risk patients from group 2 (25% vs 44%), although this was not statistically significant. As expected, all low-risk patients survived (P = .0001). Plain thorax x-ray was diagnostic in 23 (82.1%) cases, initially normal in 3, not performed in 1, and misinterpreted as right lower lobe pneumonia in 2. At operation, the prosthetic patch was required in 2 (9%) of 22 cases and the peritoneal sac was found in 4 (13.7%). CONCLUSIONS (1) The rate of prenatal diagnosis of RCDH was low and remained stable throughout the examined period. (2) The introduction of a treatment protocol, using high-frequency oscillatory ventilation since birth, improved the survival of high-risk patients with RCDH, although the data did not reach statistical significance. (3) The majority (75%) of low-risk patients presented beyond the first week of life with a variety of aspecific gastrointestinal or respiratory symptoms that accounted for initial misdiagnosis. (4) Even in these cases, the outcome was excellent.
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Affiliation(s)
- Paola Midrio
- Department of Pediatric Surgery, University of Padua, 35121 Padua, Italy.
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Robertson DJ, Harmon CM, Goldberg S. Right congenital diaphragmatic hernia associated with fusion of the liver and the lung. J Pediatr Surg 2006; 41:e9-10. [PMID: 16769329 DOI: 10.1016/j.jpedsurg.2006.02.031] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
We present the case of a male infant at a gestational age of 41 weeks who presented with a right congenital diaphragmatic hernia. During surgical exploration, right hepatopulmonary fusion was encountered. We review the existing literature on this problem, describe a novel surgical approach, and review the embryology of this complex lesion.
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Affiliation(s)
- Daniel J Robertson
- Division of Pediatric Surgery, Children's Hospital of Alabama, University of Alabama-Birmingham, Birmingham, AL 35233, USA
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Tanaka S, Kubota M, Yagi M, Okuyama N, Ohtaki M, Yamazaki S, Shirai Y, Hatakeyama K. Treatment of a case with right-sided diaphragmatic hernia associated with an abnormal vessel communication between a herniated liver and the right lung. J Pediatr Surg 2006; 41:e25-8. [PMID: 16516610 DOI: 10.1016/j.jpedsurg.2005.12.032] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
We herein report a rare case of a newborn girl with a right-sided congenital diaphragmatic hernia where a herniated liver had an abnormal vessel communication with the right lung. A surgical repair was initially attempted through a thoracic approach at 4 days of age where only a plication of the hernia capsule was performed without a prominent improvement in the respiratory condition. At 1 year of age, an angiographic examination was performed, which revealed pulmonary hypertension and abnormal vessel communications where the right pulmonary flow returned to the herniated liver and the right lung also received an arterial supply from the liver. During the second surgical repair performed at 1 year and 1 month of age, an abdominal approach through a right subcostal incision was selected. The aberrant vessels between the lung and the liver were carefully identified and ligated. Because the right lobe of the liver was completely herniated, a hepatic segmentectomy of S6 and S7 was performed. The patient has been doing well for 21 months without any mechanical ventilation since 2 months after undergoing the radical second operation. When performing surgery on a right-sided diaphragmatic hernia, the potential presence of such a vessel anomaly should be carefully taken into consideration.
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Affiliation(s)
- Shinji Tanaka
- Department of Pediatric Surgery, Niigata University Graduate School of Medical and Dental Sciences, Niigata 951-8510, Japan
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Keller RL, Aaroz PA, Hawgood S, Higgins CB. MR imaging of hepatic pulmonary fusion in neonates. AJR Am J Roentgenol 2003; 180:438-40. [PMID: 12540449 DOI: 10.2214/ajr.180.2.1800438] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Roberta L Keller
- Department of Pediatrics, The University of California at San Francisco and The Cardiovascular Research Institute, San Francisco, CA 94143, USA
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Slovis TL, Farmer DL, Berdon WE, Rabah R, Campbell JB, Philippart AI. Hepatic pulmonary fusion in neonates. AJR Am J Roentgenol 2000; 174:229-33. [PMID: 10628484 DOI: 10.2214/ajr.174.1.1740229] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE This report discusses the relationship of supradiaphragmatic hepatic tissue that is fused to the lung (through a diaphragmatic defect) with pulmonary hypoplasia-a new constellation of findings. CONCLUSION Hepatic pulmonary fusion should be suspected in instances of apparent diaphragmatic hernia characterized by mediastinal shift towards the hypoplastic lung or when the mediastinum does not shift away from the mass.
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Affiliation(s)
- T L Slovis
- Department of Pediatric Imaging, Children's Hospital of Michigan, Detroit 48201, USA
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